The Right of Migrants and Refugees to Access Health and Health Care Services in Turkey during the Covid-19 Period

Introduction

The COVID-19 pandemic has had a major negative impact on the entire world population, particularly on vulnerable communities, including refugees. The main reasons for this are the heavy burden of the pandemic on the economies of the countries where refugees live and the restrictions on asylum seekers’ mobility. The economic pressures on host countries manifest the most on asylum seekers, refugees and the migrants in need of humanitarian assistance or working informally. Many refugees are trapped in difficult conditions in crowded camps in transit countries such as Greece, even if they have reached the countries, they want to seek refuge. Their access to many services has been restricted due to slow bureaucratic processes.

Considering the refugees, migrants, asylum seekers and other categories of internationally displaced people in Turkey, although the statistics indicating the infection rates during the pandemic process in these communities are not known, many organisations have revealed multi-dimensional analyses and field studies on adverse effects of the COVID-19 epidemic on asylum seekers, refugees and other displaced communities with their needs.

The increasing number of positive patients as a result of incorrect use of masks, violation of social distance, and lack of attention to hygiene can be followed through current news. For refugees, asylum seekers and immigrants living in Turkey; it is of great importance to explain the curfew, the use of masks, new hygiene habits and new normals in their native languages.

People that displaced by war, conflict and humanitarian crises are often neglected, although they always face more risks and challenges than the general population in global pandemics and similar processes.

Difficulties in accessing information, mainly due to the language barrier, the worsening of existing challenges in access to livelihoods in the pandemic situation and financial difficulties, the additional health risks of crowded living and working, the inadequacies in accommodation, food and hygiene conditions, interruptions on basic rights and services, and physical barriers to access to facilities, particularly healthcare units, are among the leading causes of vulnerabilities.

In this context, it is essential to develop actions and intervention tools that will respond to the sensitivities and needs of refugees in the process of combating and responding to the COVID-19 which has been faced globally and declared a “pandemic” by the World Health Organization. Other risks include marginalization, stigma and discrimination due to the measures that can be taken against refugees, especially against irregular migrants during an emergency.

Statistics on international migration and refugees in Turkey

In Turkey, approximately, there are 3.6 million Syrians migrants under temporary protection, and 400 thousand asylum seekers and refugees under international protection. Apart from this, it is known that there are at least 1 million more irregular migrants in addition. Irregular migrants are the most vulnerable in this group, as they have not had access to healthcare for a long time.

Right to Health and Access to Health Services

The right of these people and the conditions of access to health services differ according to their current status. Syrians under “temporary protection” and conditional refugees can benefit from the General Health Insurance (GSS) as long as they live in the city stipulated by the Directorate of Migration Management. Within the scope of primary health care services, some of them benefit from the services offered in Migrant Health Centres (GSM), while others apply to family medicine. On the other hand, persons under “temporary protection” and conditional refugees who do not reside in the cities specified by the Directorate, due to business, social networks or different reasons cannot benefit from the General Health Insurance.

With the law published in the Official Gazette dated 24.12.2019; the general health insurance was terminated who has been in Turkey more than a year and who is 18 years old or older that applied (or already has) for international protection status. Except for those who can document that they are not able to pay as of January 1, 2020, they must pay their general health insurance themselves. Regular immigrants who apply for residency for various reasons (e.g., business, tourist, student or family residence permit) benefit from the private or general health insurance in the process of their stay in Turkey.

Unregistered migrants and undocumented migrants experience problems in accessing health services due to the lack of legislation covering these persons. Their access to hospitals is almost non-existent, except for emergencies. In emergency situations, some hospitals apply the health tourism circular, and some hospitals treat it as a person without health insurance. In addition to these, some hospitals notify law enforcement officers if unregistered/undocumented immigrants apply.

Services such as immunization, neonatal screening program, pregnant follow-up, baby/child follow-up, reproductive health counselling, which are offered within the scope of primary health care services in the country, are offered to everyone, including immigrants, free of charge. Irregular migrants are registered as stateless when they enter the Public Health Management System (HSYS).

Health and social services provided to refugees in Turkey

Currently, there are 180 Migrant Health Centres (GSM) in 29 provinces that provide services to refugees in our country and Foreign National Polyclinics (YUP) within the Community Health Centres in other provinces.

Migrant Health Centers (GSM):

In order to facilitate the access of Syrians under Temporary Protection to health services, Migrant Health Centers (GSM) have been established. These centres were opened in areas where refugees live to provide preventive healthcare services to alleviate the burden of hospitals. Syrian health personnel work at the GSMs and patient referral officers who speak Arabic and Turkish are also employed. This work, which is part of the SIHHAT(The Project for Improving the Health Status of the Syrian Population under Temporary Protection and Health-Related Services offered by the Republic of Turkey) project, is funded by the Ministry of Health and the European Union (Migrant Health Center, 2020). Syrian doctors, who had to leave their country due to the civil war, continue to provide health services to their citizens. It is also a significant development in terms of employability of the qualified population in the country. It is critical for Syrians who want to access healthcare services without getting stuck in the language barrier.

For healthcare workers that working in GSM, Ministry of Health translated COVID-19 algorithms into Arabic. Gloves, masks, alcohol-based hand sanitizer, surface disinfectant have been sent to the personnel and efforts are being made to meet additional demands. Fever measurement is performed at the application to GSM and patients are directed to the hospital if deemed necessary. In some GSM’s, patients are taken in groups of 5. However, when the weather conditions are bad, the application of this rule becomes difficult. Most of the GSM’s are cleaned twice a day with a solution of 10% bleach. Pregnancy monitoring, child monitoring, vaccination, etc. applications are tried to be done in separate rooms, but this may cause problems in waiting areas. Syrian doctors remind the warnings about epidemic control both on social media and to the patients who apply face to face, but it is stated by the employees that the warnings are not very effective.

Hospitals:

Interpreters are available in some hospitals to overcome the language barrier during interviews. With the change of regulation by 9th April, pandemic treatment was included in the scope of “emergency”.

With the Presidential Circular (2019/5) dated April 13, 2019, COVID-19 test and treatment was defined as a national emergency health service, paving the way for even those without social security to receive free services. Nevertheless, it shows that the fear of being deported, evacuated or losing the job led to reservations in applying to health services during this period.

Problems experienced during the diagnosis, treatment and isolation of patients:

In order to register and test -unregistered/undocumented immigrants-, “stateless” entry to HSYS has been initiated. However, the absence of a published legislation on this issue leads to differences in practice and creates problems in detecting and monitoring patients. Due to the language barrier, people under “temporary protection” or under international protection, who are positive for COVID 19, the contact tracing cannot be done as prescribed.

It is difficult to communicate with people sought for contact tracing due to the language barrier; Health personnel cannot conduct a qualified interview because of the positive situation creates a fear of deportation. It is not possible to provide the necessary hygiene conditions and proper isolation in the accommodation conditions where many people live together.

After the COVID 19 outbreak started, the unemployment rate among immigrants increased. This situation primarily affects people’s access to basic services such as nutrition and health services.

Irregular Migration During the Pandemic

Irregular migration is an issue that should be evaluated separately in terms of destination, transit and source countries. This concept covers those who come to their countries illegally or do not leave within the legal exit period for the target countries and those who cross the borders of the country in order not to comply with the necessary procedures while leaving the country of origin. For transit countries; It refers to people who enter the country legally or illegally to reach the destination country from the countries of origin and use it as a transit country. Turkey is a transit country for foreign nationals to European countries due to its geographical location.

Because of war and terror in countries such as Afghanistan, Pakistan, Iraq, Iran and Syria, the efforts of asylum seekers to pass illegally to Greece slowed down during the pandemic period compared to the previous years and months.

Research on Impacts of Covid-19 on Refugees in Turkey

Prepared by Association for Solidarity with Asylum Seekers and Migrants (SGDD-ASAM) in May 2020 in Ankara.

609 of the beneficiaries, who are between the ages of 18 and 70, are women and 553 of them are men. The nationality distribution of the survey participants is as follows; 960 Syrians, 131 Afghans, 49 Iraqis, 20 Iranians, 1 Palestinian and 1 Somali. The survey application, which was searched across 53 provinces, was answered across 48 provinces.

Covid-19 Outbreak Information Status

In the survey participated by 1,162 people, 83% of the participants stated that they have sufficient information about the COVID-19 outbreak. 65% of the participants stated that they have accessed this information via social media or other written / visual media, and 19% through their neighbours or friends. The ratio of people who stated that they were informed through the Ministry of Health and other public institutions, which are the most reliable sources in access to information, remained below 10%.

Protection Sector

Protection Sector questions were answered by 540 people. Predicting the risks of having to stay in the same house with households during the epidemic, in terms of protection, the survey participants were asked whether they left the house during the epidemic period. According to the survey results, 58% of the people stated that they rarely leave the house, while 35% stated that they never leave. The rate of people who have to leave the house every day is 6%.

Conclusion: Overall Recommendations

Primary public health measures should be implemented. Most importantly, camps require better testing and monitoring in addition to face masks, hand sanitiser and other supplies. It should be remembered that it is crucial to catch cases early to avoid larger outbreaks and that testing capacity must be increased independently of confirmed cases. However, overcrowding remains a critical obstacle to the implementation of some recommended public health measures, such as social distancing. Experts say this will require faster processing of asylum claims as well as building new facilities to help reduce the overall population of the camps. On the other hand, both of these measures require international support for refugees that is currently in decline. The pandemic and the ensuing economic crisis led to cuts in foreign aid, diverting resources domestically rather than internationally, while many countries looked inward.

Access to health insurance should be provided unconditionally for international protection applicants and status holders who are denied access to the General Health Insurance.

In order to receive treatment in the Immigrant Health Centres, the obligation to go to registered cities should be removed. This limitation prevents asylum seekers and refugees from accessing healthcare, especially in emergency diseases.

Those who are currently under the status of asylum seekers and refugees stated that they are afraid of applying to the necessary authorities and going to a doctor for fear of deportation. Public health should never be included among the reasons for deportation, and in a possible case, asylum seekers and refugees should be treated free of charge. Indeed, this condition only increases existing fears, and consequently endangers public health even more.

The damages of unregistered employment have been seen once again throughout the epidemic. It is imperative that studies on this subject begin immediately. Efforts should be made to ensure basic workers’ rights in all workplaces and to ensure that asylum seekers also benefit from these rights.

Migrants and asylum seekers should be informed of all these changes through news that will be made both in Turkish and in their own language on the website of the DGMM and related ministries, television and social media.

In order to prevent misinformation, the budget allocated for immigrants and asylum seekers used to deal with the epidemic, financial aid from the EU, UNHCR or other sources should be shared with the public transparently.

The currently provided allowances should be provided on a regular basis as long as the applicant’s conditions remain, not one-off.

During the COVID-19 pandemic, despite the fact that international travel has begun to be allowed, there are still difficulties in the process of resettlement of refugees. This situation should be resolved immediately by taking necessary health measures.

Irregular migrants, asylum seekers and refugees should be included in every phase of this process, as well as civil society, and relevant social policies should be prepared with their contributions.

In addition, 98.4% of Syrians live outside of the camps, that is, in cities. In this context, epidemic risk is a common problem. It is obvious that after the epidemic, the unknowns are discussed and the programs in which suggestions and protection methods are explained are not well understood even by the local people.

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